By CRISTINA JANNEY
Hays Post
Anthem insurance recently made headlines for its policy on denying payment for some emergency room visits for non-emergencies.
The Anthem policy initially was rolled out in four states, but that did not include Kansas.
Officials at HaysMed said its billing department has not had patients say they had problems with denial of payment for emergency room visits.
However, HaysMed emergency room doctor Dr. Derek Yarmer recently talked to the Hays Post about when it is appropriate to use the ER and what he thought the effect of possible denial of coverage for ER visits might have on patients.
Emergency rooms cover a wide array of conditions in part because they are always open and can usually perform diagnostic tests quickly, Yarmer said.
He said it can be difficult to distinguish if a person is having a health crisis until a doctor has run a battery of tests.
“It is so hard to define,” Yarmer said. “Someone falls awkwardly on their ankle. If it is a sprain, it is not an emergency. If it is broken, it needs to be splinted. You don’t know until you get the X-ray.”
Symptoms that definitely should result in a trip to the ER include chest pain, symptoms of a stroke and bad infections.
On the opposite extreme, maladies such as earaches, coughs, colds, and bumps and bruises are probably conditions that can be addressed by a primary care physician or at urgent care.
Cost is the primary reason insurance companies have sought to rein in emergency room visits.
The base charge for a trip to the ER is $1,000 in Hays. An office visit to a primary care provider runs about $105, and the cost of a visit to urgent care is the same.
In an addition to higher costs, ERs doctors complete more complex and often more costly tests than primary care doctors.
“I am boarded in emergency medicine, so if you come to the ER, you basically declare you have an emergency,” Yarmer said. “It is my job to prove you do or don’t. If you do, then I treat it. We do a lot more CT scans trying to find something wrong as opposed to the mindset of a primary care doctor where they will see you in clinic where they will do some blood work and see you back in a day or two. We don’t have that luxury. We have one shot to prove or disprove you have an emergency.”
Receiving care for non-emergent conditions from a primary care physician can not only be cheaper but better for the patient.
The American Academy of Family Physicians reported in 2015 that a study in California indicated those who maintained a relationship with a primary care physician were less likely to use the emergency room or be admitted to the hospital.
Nadereh Pourat, Ph. D, noted in an article for the AAFP on her study those patients who received regular primary care received preventive care such as medication management, weight management and exercise plans.
Data from the HaysMed indicated 23.6 percent people served in the ER did not report having a primary care physician, but it is not necessarily because they didn’t have insurance. Self-pay patients made up 9.5 percent of those served at the HaysMed ER.
Regardless of insurance or primary care status, the majority of Americans are saying they are using the ER because they think they have a condition serious enough to warrant it. A National Health Statistics Study released in 2016 indicated 77 percent of respondents age 18 to 64 went to the ER because of the seriousness of their condition, 12 percent went because their doctors’ offices were closed, 7 percent went because of lack of access to other care and the rest gave no reason.
Although there may be benefits in encouraging patients to seek care from a primary care physician, Yarmer said policies that create fear of denial for ER care can be detrimental. Yarmer gave another example.
“You don’t know if it is an emergency until we do some testing,” he said. “People come in for chest pain that ends up being acid reflux. Two totally different things, but if you are having a heart attack, that is definitely an emergency, but acid reflux isn’t. You don’t know until you get the testing done to rule it out.
“I think if you start limiting access to the emergency department or (create) fear of being penalized financially for it, then people probably won’t come in for their chest pain,” he said.
Attempts have been made in the past to curtail ER use, Yarmer said, but he said it is difficult for the average person to know when a condition is not an emergency.
“I think it is dangerous to threaten people with not paying for them to be seen. I can understand the insurance companies want efficient care. There are a lot of things that we see in the ER that could be seen in a different clinic, but I think once you start threatening to not reimburse, there are going to be people who have bad outcomes — missed heart attacks, missed strokes — things like that. People are going to be just too worried about the bill.”